![Shalloway & Shalloway, P.A. - Elder and Special Needs Attorneys. Dedicated to preserving dignity and financial security](https://www.shalloway.com/wp-content/themes/shalloway_2019/img/logos/main-v2.webp)
Consultation Today
- Tel: 561-686-6200
- Fax: 561-686-0303
Medicare, established in 1965, is a federal health care plan for those 65 and older, in addition to certain persons under 65 (e.g., the disabled). In the event a Medicare recipient is injured through the fault of another, he or she may have the right to recover from the person causing injury (or his or her insurance company).
Medicare
Medicare was initially the “primary payer” for medical services to beneficiaries, meaning that it paid first for medical costs, even where other sources existed. However, high costs led Congress, beginning in 1980, to enact “Medicare Secondary Payer” (MSP) laws. The MSP legislation sought to reduce Medicare costs by requiring beneficiaries to first exhaust other sources of payment before resorting to Medicare.
Medicare Payment for Treatment of Injuries
Federal law generally prohibits Medicare from paying for any item or service where payment can reasonably be expected from another “primary” source within 120 days. Primary sources include the following:
When payment from another source is probable, yet not likely to occur within 120 days, the law allows “Conditional Medicare Payment” for medical costs. Although Medicare providers are often required to question patients regarding possible alternative sources of payment, as a practical matter, the agencies that run Medicare have little way of knowing about such alternatives. As a result, “conditional payment” is often made.
Medicare Reimbursement: Rights and Duties
The MSP system includes provisions for reimbursement and “subrogation.” In other words, Medicare succeeds to the rights of the injured party to sue the injuring party, or others, for recovery. Further, the administration of enforcement efforts of Medicare reimbursement rights has been contracted out to HGS Administrators (HGSA).
Debate has taken place over the nature and extent of Medicare’s right to recover. Some commentators, for example, have called it a “super lien” against any settlement or judgment in a personal injury lawsuit. Strictly speaking, the right to recover does not technically constitute a lien (i.e., not a right to recover from specific property or funds). However, the MSP program grants extensive powers and specifies broad rights and duties related to reimbursement of “conditional payments.” These include, but are not limited to:
Waiver or Compromise
Depending on the circumstances, Medicare may waive its right to reimbursement, though it is more likely to compromise the amount. Under applicable regulations, Medicare will reduce its recovery to allow for the cost of procuring the settlement or judgment, including attorneys’ fees.
© 2024 NextClient.com, Inc. All rights reserved.